Each year 3.2 million stillbirths occur globally. In the U.S. and other developed countries, stillbirths is a largely under-studied perinatal outcome despite being one of the most common adverse pregnancy outcomes, accounting for one-half of all perinatal deaths. In 2006, the most recent data available for the U.S., stillbirths occurred in 6.05 of every 1,000 live births plus fetal deaths, much higher than many high-income countries and the U.S. Healthy People 2020 Objective of 5.6 (per 1,000 live births + fetal deaths) for fetal mortality rates. Stillbirths are poorly ascertained in the United States and most developed and developing countries. The most recent national data available on stillbirth prevalence is from 2006 which underscores the insufficient infrastructure currently in place for ascertainment and monitoring of this important perinatal outcome. In 2005, the Centers for Disease Control and Prevention (CDC) explored the feasibility of expanding two existing state birth defects surveillance programs, and the success of these pilot studies demonstrated that expanding current methods of existing birth defects registries for stillbirth surveillance is a viable and cot-effective method for surveillance of stillbirths. CDC announced a new initiative, which is a supplement to the Birth Defects Study to Evaluate Pregnancy exposureS (BD-STEPS) study, to pilot the expansion of existing state birth defects registries in the Centers for Birth Defects Prevention and Research to include surveillance of stillbirths without birth defects and to conduct pilot studies to investigate modifiable risk factors for stillbirths. The Arkansas Center's long-term goal is to prevent or significantly reduce the occurrence of birth defects and adverse pregnancy outcomes. We propose to implement a population-based, active surveillance system of stillbirths without birth defects in Arkansas; identify novel modifiable pregnancy exposures that decrease the occurrence of stillbirths by participating in this pilot study as a supplement to BD-STEPS; and discover gene- environment interactions that lead to stillbirths by supporting high-throughput genomic and epigenomic analyses of biological samples collected from NBDPS and BD-STEPS participants using institutional and extramural funds that augment CDC funding. Through our studies, we will maintain a leading role in establishing health strategies to prevent birth defects and stillbirths.